Article Text

Download PDFPDF

GRP-159 Retrospective Analysis of Most Frequent Risk Errors Related to Informatization System For Prescribing and Administering Medication
  1. N Bensalah1,
  2. G Jabaud-Gazin2,
  3. M Badin1,
  4. M Camus1
  1. 1CH Marc Jacquet, Department of medical informatization, Melun, France
  2. 2CH Marc Jacquet, Pharmacy, Melun, France


Background Although implementing an electronic system shows significant functional effects associated with saving time, reducing costs and contributes to a safe medication process by improving patient safety and quality of service, it can also cause confused actions leading to new types of medication errors (MEs).

Purpose To identify and classify the most frequently observed MEs generated by the computerised tool when prescribing (physician order) and administering drugs (nurses’ work).

Materials and Methods In June 2011, Orbis Medical (AgfaHealthcare) software was introduced in our hospital for the medication process including integrated electronic prescription, pharmaceutical analysis and administration (4 clinical units representing 107 beds). Different risks of error were identified during pharmaceutical interventions (PIs) recorded between June 2011 and October 2012 and classified according to the French Society of Clinical Pharmacy recommendations. The focus is on MEs related to computerisation.

Results 605 PIs were made on 3933 prescriptions supplied over 466 days. Among these notifications, 1/3 were attributable to the use of the electronic system. Most MEs reported were due to: 1-regarding the prescription: incorrect dose regimen due to selecting the wrong units, incorrect schedule for dose administration, misuse of the commentary zone (free full text related to specific information), redundancy of 2 lines of the same prescribed drug, false interpretation of alert message; 2-regarding administration: failure to record administration, wrong drugs selected to be administered, misuse of the philtre function, single validation for different schedules.

It was noticed that MEs decreased after the staff had used the software for a period of time.

Conclusions Introducing an electronic tool may have an impact on professional practise. Although making healthcare processes safer, it generates new types of iatrogenic harm (other studies have revealed 5–35% MEs were attributable to computerisation). The introduction of new technology should be accompanied by regular training and evaluation to prevent misuse and potential adverse events.

No conflict of interest.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.